Hospitalist-led medicine emergency department team: associations with throughput, timeliness of patient care, and satisfaction.

BACKGROUND: Admitted patients boarding in the emergency department (ED) leads to hospital diversion. Active bed management and care for boarded patients can improve throughput. We developed a hospital medicine ED (HMED) team to participate in active bed management, and to care for boarded patients, to decrease diversion and improve throughput. METHODS: An HMED team was created to participate in active bed management and to care for boarded patients. The HMED team worked with the ED, nursing supervisors, and medical floors to manage inpatient beds. The primary outcome was percentage of hours of diversion attributed to lack of bed capacity. Secondary outcomes included the proportion of patients discharged within 8 hours of transfer to a medical floor, and the proportion of patients discharged from the ED. Promptness of clinical care was measured by rounding times. Satisfaction was obtained via survey. RESULTS: There was a relative reduction of diversion due to medicine bed capacity of 27% (4.5%-3.3%; P < 0.01), a relative reduction in the percentage of patients transferred to a medicine floor and discharged within 8 hours of 67% (1.5%-0.5%; P < 0.01), and a relative increase in the number of discharges from the ED of admitted medicine patients of 61% (4.9%-7.9%; P < 0.001). Boarded admitted patients were rounded upon 2 hours earlier (P < 0.0001) by the HMED team. Satisfaction with the HMED team was high. CONCLUSION: An HMED team can improve patient flow and decrease ED diversion while providing more timely care to patients boarded in the ED.

Artifact simulating fracture on cervical spine computed tomography.

We present the case of a 31-year-old trauma patient with computed tomography concerning significant C3-C4 subluxation. The abnormality is due to an artifact with which emergency physicians should be aware.

A confirmed case of agranulocytosis after use of cocaine contaminated with levamisole.

More than 2 million Americans use cocaine each month (National Survey on Drug Use and Health, Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (SAMHSA) & Office of Applied Studies (OAS), Rockville, MD 2007). Starting in early 2003, South American cocaine cartels began to add levamisole, a pharmaceutical agent, to bulk cocaine prior to shipment to the USA (Valentino and Fuentecilla 2005). A dramatic increase in the prevalence of levamisole in cocaine was noted in early 2008. By October, 30% of cocaine bricks analyzed by the United States Drug Enforcement Administration contained levamisole (Casale et al. 2008). Exposure to levamisole can cause agranulocytosis (Amery and Bruynseels 1992). We report the first confirmed case of agranulocytosis associated with consumption of levamisole-contaminated cocaine in the USA. A previously healthy adult male presented to the emergency department with 5 days of mouth pain. He admitted to chronic active ethanol and crack cocaine abuse. Laboratory studies revealed severe neutropenia, with an absolute neutrophil count of 19 cells/mm³ (normal = 1,500-8,000 cells/mm³). A urine screen for drugs of abuse was positive for cocaine metabolites and opiates. Evaluation of a peripheral blood smear showed leukopenia with severe absolute neutropenia. A bone marrow biopsy revealed recently injured bone marrow showing early recovery. While in the hospital, the patient had little spontaneous bone marrow recovery. He received granulocyte colony-stimulating factor with improvement in peripheral white blood cell counts. The residue in the patient's crack pipe contained 10% levamisole. Subsequently, levamisole was detected in the patient's urine. Levamisole-associated agranulocytosis should be considered in the diagnosis of patients who present with neutropenia and a history or evidence of cocaine use.

Identifying inaccuracies on emergency medicine residency applications.

BACKGROUND: Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. METHODS: This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. RESULTS: Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 35.0-47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4-23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. CONCLUSION: This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals.